REVEW ARTICLE

Dr Souradip Banik
Moderator- Dr J S Bhasin
 INCORPORATING DEVELOPMENTAL
SCREENING AND SURVEILLANCE OF
YOUNG CHILDREN IN OFFICE
PRACTICE
SHARMILA B MUKHERJEE, SATINDER ANEJA, *VIBHA
KRISHNAMURTHY AND *ROOPA SRINIVASAN
INTRODUCTION

 Development is a continuous process

 Occurs normally in childhood,
 Skills are acquired in various inter-related developmental domains.
 It is intricately influenced by a combination of genetic, biological and
psycho-social factors .
 Pediatricians frequently face parental concerns regarding development
and/or behavior .
 Some of these issues may be transient and easily rectifiable but a small
but significant proportion may actually be harbingers of neuro-
developmental disorders
PREVALENCE

 Global prevalence of developmental delay in children - 1-3%

 World Health Organization (WHO) estimates that 15% of the world’s
population lives with some form of disability
 Paucity of community-based data from lower and middle income
countries (LMIC), but a similar or higher prevalence is expected .
WHY DEVELOPMENTAL SCREENING
IS NOT ROUTINELY PRACTICED IN
INDIA?
 In India, there are multiple challenges to practice of universal
developmental surveillance and screening.
 Parents are unaware of the existence and need of these services.
 Health care seeking is prioritized for acute illnesses which are not
appropriate opportunities for screening.
 If parents express concerns, Doctors often given false assurances
without proper appraisal.
 Well-child visits are primarily for immunization with a few
perfunctory questions asked about development, if at all
 A study of perceptions and practices of 90 pediatricians from Gujrat .
 Most participants (97.3%) reported parents expressing developmental
concerns
 Only 13.6% used structured tools for evaluation.
 Reasons –
 time constraints (72%),
 nonavailability of treatment or referral options (45%),
 inability to use screening tools (28%).
 Common misconception, informal evaluation has been proved
unreliable in detecting developmental delay.
 Recognition is difficult in early childhood unless specifically looked
for in a structured way, since changes in development are rapid, there
is intra-domain overlap, and early indicators are often subtle.
 Available assessment tools are mostly of international origin, which
are expensive, not easily available, and require training and
accreditation.
 Recommendations for developmental screening by the Indian
Academy of Pediatrics (IAP) are yet to be formulated
INDIAN RECOMMENDATION

 The ‘Persons with Disabilities Act, 1995’ states that

 Children should be screened annually to detect high risk cases’, the
process is not outlined .
 In 2013, the ‘Rashtriya Bal Swasthya Karyakram (RBSK)’ was launched by
the Government of India, which aims at
 screening for defects at birth, diseases, deficiencies and development
delays including disabilities (4 D’s) in children between 0 to 18 years .
 It is envisioned that pre-school children will be screened
by Anganwadi workers using age-appropriate developmental checklists in
the periphery and the positive cases will be re-assessed by trained personnel
at the secondary and tertiary care levels
 DEVELOPMENTAL SCREENING TOOLS
IN USE IN INDIA

Screening tools currently in use in India include

those developed and validated in high-income countries,
translations of the above in Indian languages, and
Indigenously developed tooll

Internationally acclaimed tools may not be suitable for our populations due to

presence of items that are culturally alien or which lose context after translation.
 Indian tools are language and culturally suitable
 Validated but may not have optimal psychometric properties since
most were originally developed largely for community surveys by
health workers.
 A list of screening tools for developmental delay popularly in use or
validated in Indian settings was compiled and reviewed.
 Tools screening for behavior problems or specific domains or overt
disability were not included.
ANALYTICALLY COMPARING TOOLS
FOR DEVELOPMENT SCREENING

 To compare tools qualitatively, it is essential to understand their characteristics

 Choice of tools also differs according to level of risk for developmental delay;
 High-risk children - biological and/or environmental risk factors.
 Constituent items of tools may be historically based (milestones, opportunity-
based skills), performance-based or both.
 In contrast to developed counties, parental interviews are not as reliable in
LMICs due to poorer literacy levels, unawareness of milestones and possibility
of socially acceptable responses being given due to associated social stigma .
 Interpretation of a screening result as pass or fail is done by comparing with
scores derived from standardized population norm-references or pre-decided
performance
PROPERTIES OF SCREENING TOOL
DECIDING THE TOOL BEST SUITED
FOR INDIAN CHILDREN

 An ideal screening tool for Indian children is a

 brief,
 inexpensive tool
 good psychometric properties,
 available in Indian languages,
 comprising of purely developmental/culturally-adapted items
 validated on representative healthy Indian children and requiring minimal
training
 Such a designer tool does not exist in reality

 Each pediatrician has to make an educated choice best suited for individual
practice.
 Screening tool should be sensitivity and specificity of >70%
INTERNATIONAL TOOLS
INDIAN TOOL
DEVELOPMENTAL SCREENING IN
OFFICE PRACTICE

 Setting up routine screening practice involves

 Creating parental awareness and demand,
 Finding the right opportunity
 Tool selection
 Acquisition and training in administration, scoring, interpreting results and
counseling.
 This entails planning when, where, and how screenings will be
accomplished, devising a method for documenting observations and
maintaining records, communicating results to parents, referring to
experts for further evaluation when required and scheduling future
screening
 Visits for acute illnesses are not appropriate opportunities for
screening
 Screening can be done with pre-existing scheduled visits like
immunization and vitamin A prophylaxis.
 A system needs to be devised to document results, maintain and
update records at subsequent visits.
 Comparison with previous records helps to recognize potential
developmental problems or regression, deviancy or dissociation
AN ALGORITHMIC APPROACH TO
DEVELOPMENTAL SCREENING
CONCLUSIONS

 Many parents and children struggle in their daily lives due to

problems arising from undetected development delay.
 Considering the widespread prevalence of developmental problems,
the pediatrician must remain vigilant.
 By adopting developmental screening and surveillance, one can
ensure a systematic approach to children with developmental
concerns and help improve their future.
 Both strategies are
 integral parts of child healthcare,
 Benefit the individual child and society,
 Protect the doctor from possible future litigation.